Provider Demographics
NPI:1316519556
Name:LOVELACE, WILLIE EMMIT III (MS, ST)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:EMMIT
Last Name:LOVELACE
Suffix:III
Gender:M
Credentials:MS, ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-5948
Mailing Address - Country:US
Mailing Address - Phone:912-655-9472
Mailing Address - Fax:
Practice Address - Street 1:2122 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-5948
Practice Address - Country:US
Practice Address - Phone:912-655-9472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANA.101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health